1. Suppression of the deceased child’s name and any identifying information from publication. 2. The detail and identities of the perpetrators of any intra familial abuse suffered by the deceased child is suppressed from publication.

Summary : The deceased was a child in the care of the Department for Child Protection and Family Support at the time of his death on 15 November 2010. The deceased was 15 years of age.

The inquest focused on the quality of the supervision, treatment and care that the deceased received while in the care the Department for Child Protection and Family Support.

The Coroner found the deceased was an adolescent aboriginal boy who suffered an early infancy of neglect, in that he was deprived of appropriate responsive care during crucial times for the development of his frontal executive brain functions. The Coroner found the deceased was placed in a safe, protective, loving and supportive environment after 4 years of age, but despite this the deceased remained vulnerable to a lack of impulse control around times of normal adolescent stress.

The Coroner found the deceased died as a result of ligature compression of the neck (hanging) on 14 November 2010. The Coroner found death arose by way of Suicide.

The Coroner found the Department for Child Protection and Family Support placed the deceased with the best possible supervision, treatment and care, despite which the deceased committed suicide.

Catch Words : Department for Child Protection and Family Support : Suicide